An Integrated Career and Competency Framework for Nurses ...training and education in each...

An Integrated Career and Competency Framework for Nurses in Aesthetic Medicine.

September 2015

A C C R E D I T E D

This programme has been accredited by the RCN Centre for Professional Accreditation until 7 October 2016.

Accreditation applies only to the educational content of the framework and does not apply to any product

BACN Foundations of Aesthetic Nursing Care All works accredited by the BACN for publication must be compliant with the underlying BACN foundations of aesthetic nursing care:

F1 - Aesthetic nurses provide nursing care that is in accordance with the NMC Code (2008) and maintain professional registration to practice through continued professional development and evidence-based lifelong learning.

F2 - Aesthetic nurses are accountable for their own actions and the care they provide, underpinned by the ethical principle of non-maleficence (to do no harm), abiding by British law and practicing within the requirements of the NMC.

F3 - Aesthetic nurses underpin all practice with evidence based knowledge and rationale to achieve higher standards of care, safety, and positive experiences.

F4 - Aesthetic nurses facilitate and encourage a wider learning environment for the development of colleagues and people in their care.

F5 - Aesthetic nurses place the people they provide service to at the heart of the care they provide, without commercial bias, considering the person’s dignity, humanity and equality, through compassionate and individualised care planning, that is based upon the person’s needs and requirements.

F6 - Aesthetic nurses incorporate a biopsychosocial approach to the care they provide, encompassing all elements and their interactions, enabling a holistic and complete understanding of the person’s health and well-being.

F7 - Aesthetic nurses ensure that people in their care are empowered in decision-making by providing full information of the treatment choices available, including the risks and benefits, allowing people to make fully informed decisions.

F8 - Aesthetic nurses recognise that communication, communication skills, and confidentiality, are vital components of the aesthetic care they provide.

F9 - Aesthetic nurses adopt a multi disciplinary approach in order to utilise referral pathways, learn and develop within their own professional spheres, as well as with multi-disciplinary members, to ensure the best level of holistic care is provided.

F10 - Aesthetic nurses promote and apply a continuous approach to risk assessment and management for the safety of people within the aesthetic health care setting.

A C C R E D I T E D

A C C R E D I T E DAcknowledgments

We would like to thank all the nurses providing non- surgical cosmetic services for helping to develop

this aesthetic nursing competency framework. They gave their time and expertise in both drafting and

commenting. We would also like to thank the professionals and organisations that responded to the

consultation. This includes nurses, doctors and consultant surgeons working in the speciality, as well

as other organisations and service providers. All their comments have been incorporated into the final

document.

Finally, our thanks to the professionals noted below who provided critical reviews of earlier drafts of

this competency document.

Competency Development Group

Suzanne Armstrong, Aesthetic Nurse Practioner

Adrian Baker, Aesthetic Nurse Practioner

Liz Bardolph, Aesthetic Nurse Practioner

Sharon BenneM, Aesthetic Nurse Practioner

Emma Davies, Aesthetic Nurse Practioner

Sharon Dobbs, Aesthetic Nurse Practioner

Michelle Irving, Aesthetic Nurse Practioner

Lou Sommereux, Aesthetic Nurse Practioner

Critical Reviews

Dr Kay Baxter, MRCP (UK) LL.B, Consultant Dermatologist

Marie DuckeM RGN, Aesthetic Nurse Practitioner

Dr Rajiv Grover, MBBS, FRCS, Consultant Plastic and Reconstructive Surgeon

Professor Ian Peate RN, DipN (Lond.) RNT, BEd (Hons), MA, LLM, Independent Consultant

Dr Joe Armstrong, PhD, MSc, PG Dip. CBP, RMN

This publication is copyright material and must not be copied, reproduced, transferred, distributed, leased, licensed or publicly performed or used in any way except as specifically permitted in writing by the BACN, as allowed under the terms and conditions under which it was purchased or as strictly permitted by applicable copyright law. Any unauthorised distribution or use of this text may be a direct infringement of the author’s rights and those responsible may be liable in law accordingly. Copyright © BACN 2015

The BACN have produced this competency framework in good faith, to provide benchmark standards of practice. The BACN and RCN cannot be responsible for an individuals practice and do not confirm competence of any practitioner.

The right of the BACN to be identified as the author of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.

Contents

Section 1 – Introduction ...................................................................................................................

The Development of The Competencies ...........................................................................................

What is Medical Aesthetics? .............................................................................................................

The Role of The Nurse in Medical Aesthetics ....................................................................................

Section 2 - - About the Framework ...................................................................................................

Benefits of the Framework ................................................................................................................

The Theoretical Basis of the Competencies .......................................................................................

The Competence Levels .....................................................................................................................

Section 2.1 Getting Started ................................................................................................................

How to Use the Framework ...............................................................................................................

How to Produce Evidence to Demonstrate Competence ..................................................................

What is Evidence? ..............................................................................................................................

Section 3 – The Core Competencies .................................................................................................

Legal and Ethical Issues .....................................................................................................................

Risk Management ..............................................................................................................................

Equality and Diversity ........................................................................................................................

Communication, Information Sharing/Management ........................................................................

Medicines Management ....................................................................................................................

Clinical Governance ...........................................................................................................................

Personal Learning and Development ................................................................................................

Section 4 – The Competencies...........................................................................................................

Specialist competency 1: Learning and Development .......................................................................

Specialist competency 2: Assessment, Consent & Psychological Care ..............................................

Specialist competency 3: Skin Health Rejuvenation ..........................................................................

Specialist competency 4: Chemical Peels ..........................................................................................

Specialist competency 5: Percutaneous Collagen Induction..............................................................

Specialist competency 6: Non- permanent (bio- -degradable) Dermal Fillers .....................................

Specialist competency 7: Chemical Denervation ...............................................................................

Specialist competency 8: Sclerotherapy ............................................................................................

Specialist competency 9: Thermocoagulation ...................................................................................

Specialist competency 10: Laser/IPL ..................................................................................................

References .........................................................................................................................................

Appendices ........................................................................................................................................

Appendix 1: Competency Based Career Trajectory ............................................................................

Appendix 2: Skin Classification Systems .............................................................................................

Appendix 3: Biographies ....................................................................................................................

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Section 1

Introduction

A C C R E D I T E D

Section 1 – Introduction

In recent years, there has been an increasing demand from the public for medical aesthetic treatments and a corresponding increase in the range of treatments available. It has been estimated that approximately 1.3 million cosmetic procedures are carried out in the UK each year, and that non- surgical injectable treatments account for 92% of the total (Mintel, 2012). For decades, nurses have been providing non- surgical treatments and have played an important role in the establishment of the medical aesthetic speciality. At present, aesthetic nursing can be regarded as a distinctive and specialist area of nursing practice that is rooted in core nursing principles and a commitment to a set of professional standards and competencies.

The document provides an update to the existing BACN Competency Framework (BACN, 2013), and is intended as a guide to practice for nurses working in medical aesthetics. It will also be of interest to the increasing number of nurses who want to practice in this field and wish to understand more about this discipline.

The framework recognises the specialist and evolving nature of aesthetic nursing and the need to provide clear and consistent guidance for practitioners that will help them to identify and develop competence. In particular, the framework acknowledges that aesthetic nurses require specific, specialist knowledge and skills at different levels of practice. Moreover, the framework advocates the need to establish and maintain appropriate standards of education, training and practice to ensure nurses in aesthetic medicine possess the requisite knowledge, understanding and skills to provide professional and ethical treatment and care to patients, according to their level of competence.

In April 2013 recommendations were published by the Department of Health Cosmetic Interventions Review Panel. The recommendations included the requirement for all practitioners to demonstrate training and education in each non- surgical speciality in which they practice. The Integrated Career and Competency Framework for Nurses in Aesthetic Medicine is an essential guide for education in individual non- surgical aesthetic procedures. It can also be used to enable a structured, educational framework of learning for Higher Educational Institutions to comply with the Department of Health recommendations.

The practice of examination, supervision, assessment, appraisal and revalidation are key components of the review and have been taken into account within these competencies, along with other recommendations made. The publication of further recommendations by the Department of Health implementation team is awaited.

It is against this background that the revised competency framework has been prepared by a group of specialist nurses working within this field of practice. It is NOT intended to be exhaustive or prescriptive, but rather a template to benchmark best practice and evaluate education, training and competence in aesthetic nursing.

It is recommended that this competency framework is used in conjunction with The Royal College of Surgeons Professional Standards for Cosmetic Practice (RCS, 2013) to ensure that general professional standards of practice in aesthetic medicine are known and adhered to for the safety of the public.

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The Development of The Competencies

“Education is a journey not a destination” (Stooke, 1937)

The competencies described in this document were first published in 2005 and subsequently updated in 2007 and 2013 (RCN, 2005; 2007 & BACN, 2013; 2014). They provide an overarching framework that is intended to facilitate the enhancement of practitioner knowledge and skills and thus promote the safety and quality of patient care. The original Competency Framework for Nurses in Aesthetic Medicine owed its development to a group of nurses who were concerned for standards of practice, multi- -disciplinary collaboration and professional development opportunities.

These revised competencies were written by a Competence Development Group representing specialist nurses working in aesthetic medicine. The group included members from the British Association of Cosmetic Nurses (BACN) and the Royal College of Nursing (RCN).

The Development of The Competencies

Medical Aesthetics (also known as Aesthetic Medicine, Cosmetic Medicine, Appearance Medicine or Anti-Ageing Medicine) is a developing clinical speciality distinct from plastic surgery. It provides evidence-based, non-surgical and minimally invasive medical treatments which are intended to repair, restore or maintain healthy skin. Cosmetic medical treatments can address specific facial features and/or contours, as well as the hands, neck and décolleté or to address conditions such as acne, scarring, facial asymmetries, lipoatrophy and hyperhidrosis. The procedures are elective and performed on adult patients who are healthy and provide informed consent for treatment. Cosmetic medical treatments can enhance self-confidence and self-esteem and improve psychological wellbeing and quality of life (Castle, 2002).

The Role of The Nurse in Medical Aesthetics

The role of the nurse in medical aesthetics evolved from partnerships between specialist nurses, plastic surgeons and dermatologists. Initially, nurses were required to learn new skills related to skin resurfacing and dermal augmentation, which subsequently expanded to include other approaches such as chemical denervation, laser treatment and skin rejuvenation (Campion, 2012).

Contemporary practice in medical aesthetics requires nurses to possess specialist clinical skills and knowledge to competently assess and diagnose conditions in order to provide patients with effective treatments, which seek to reduce premature ageing and improve wellbeing. More broadly, in the area of health promotion and age -management, medical aesthetic nursing can be seen to be concerned, not only with holistic approaches to wellbeing, but to the reduction of disease. The underpinning ethos of medical aesthetic nursing is one where patient safety is first and foremost and where nursing care is based upon a clearly defined nursing process and the pursuit of excellence in practice.

In an era that has seen significant changes of the roles within nursing, medical aesthetics has become a popular speciality. The aesthetic nurse’s role requires specialist clinical competencies, entrepreneurial skills, expertise in managing the patient journey from assessment and diagnosis through to treatment selection and planning, delivery and follow up. The ability to build and sustain partnerships with patients, underpinned by respect, trust and loyalty, is a critical element of the role of the nurse in medical aesthetics.

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As the role of the nurse in aesthetic medicine has evolved, it has inspired some of the finest examples and models of effective nurse enterprise. This has challenged traditonal concepts and stereotypes, not only in nursing terms, but in relation to models of practice in the independent medical sector, where, unlike their aesthetic nursing colleagues, nurses in other specialities are not normally present in full-time private practice. Working in medical aesthetics affords the nurse with exciting opportunities to practice autonomously in a challenging and dynamic area of practice. It should be noted, with these exciting opportunities to practice autonomously, comes responsibility; It is a legal requirement that all nurses have appropriate indemnity arrangements in place in order to maintain NMC registration (NMC, 2015). More information on this can be found at: http://www.nmc-uk.org/Registration/Professional-indemnity-arrangements/

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Section 2

About the Framework

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Section 2 - About the Framework

Benefits of the Framework

The framework sets out the competencies as a benchmark for good practice, which may be used to evaluate safe and effective nursing. Furthermore, the framework aims to provide a robust foundation upon which to protect members of the public seeking aesthetic treatments and promote a research- informed and competency based approach to practice.

The competency framework not only provides benefits for nurses, but also for their employers, patients and the public. Using the framework will help nurses to:

• deliver consistently high standards of evidence based care

• identify the nurse’s level of practice, enabling them to develop in a more structured way

• pinpoint educational needs to help achieve personal potential more effectively

• seize opportunities to influence the direction of nursing at a strategic and political level

• provide support for nursing appraisal and identification of development needs.

The framework will give employers:

• a benchmark of professional development and continuous improvements to evaluate employees performance

• clearer insight into the expertise and competence of staff, for example, to assess risk management

• Support for nursing appraisal and identification of development needs.

Patients and the public will benefit from the framework because it will support:

• higher standards of patient care

• increased effectiveness of service provision

• improved access and choice for care provision.

The Theoretical Basis of the Competencies

The competencies defined in this framework are informed by Benner’s (1982; 2001) theory of professional development in relation to nursing practice. Benner’s model (1982; 2001) proposes that the acquisition of professional knowledge and skills in nursing is characterized by a progression through five stages of development: 1) novice; 2) advanced beginner; 3) competent; 4) proficient; and 5) expert.

The rationale for using Benner’s (2001) model is that it is supported by research and widely applied in the nursing profession, and importantly, it provides a clear framework within which to benchmark and evaluate competence in relation to aesthetic nursing practice. For the purposes of this document only

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the competent, proficient and expert stages of development will be considered in the competencies statements that follow. This is because there is consensus among aesthetic nurses that aesthetic nursing practice should only be undertaken by registered nurses who have undertaken appropriate training and supervised practice in aesthetic medicine. Within this competency framework, it is only when the nurse reaches the competent stage of development that they are regarded as having met minimum training requirements and accrued sufficient experience to practice autonomously as an aesthetic nurse.

For the purposes of this document, the novice aesthetic nurse will be undertaking specialist education and training, which will include shadowing and observing a specialist aesthetic practitioner, but not actively engaged in treating patients. During the advanced beginner stage of development, the aesthetic nurse will continue their training, while building a portfolio of practice- - based experience, and will only practice under the supervision and mentoring of a specialist aesthetic practitioner.

A brief outline of each stage of Benner’s model is provided below.

Stage 1: Novice - The aesthetic nurse begins specialist training and educationThe novice has no experience in the situation in which they are expected to perform. Nurses at the novice stage may be new entrants to the profession or experienced nurses that are changing to a new area of practice (e.g. Aesthetic Nursing). At this stage, the practitioner lacks confidence to demonstrate safe practice and requires continual verbal and physical cues. Typically, the nurse’s decision making and performance is based upon explicit rules which are often applied in a rigid and indiscriminate manner.

Stage 2: Advanced Beginner - The aesthetic nurse develops practical skills under direct supervisionThe advanced beginner has experience in actual situations and is able to demonstrate marginally acceptable performance. The accumulation of some prior experience provides the basis for the advanced beginner to begin to make basic clinical judgements and to formulate principles to guide their practice. The nurse at this stage can demonstrate skilled performance in some areas, but still requires support and guidance from a mentor to further develop their competence.

Stage 3: Competent - The aesthetic nurse is working with confidence and continues to develop practice with peer supportThe competent nurse has confidence in their actions and decisions and is able to demonstrate and evidence good patient outcomes. The competent nurse has acquired practical knowledge through experience and is further developing their knowledge and skills with support and guidance from a range of sources, which should include peers and mentors.

Stage 4: Proficient - The aesthetic nurse is working autonomously with the use of diagnostic and management skillsThe proficient nurse practices holistically and makes treatment decisions based on a comprehensive assessment of the patient’s needs. The proficient nurse learns from experience how to interpret and manage patient expectations, is able to devise an appropriate treatment plan in concordance with the patient and responds constructively when expected outcomes are not achieved.

Stage 5: Expert - The aesthetic nurse is working from a deep, evidence based, understanding of aesthetic practice as a whole, and leads in nursing competence.In addition to an evidenced- -based approach, the expert nurse also has an intuitive grasp of each patient’s concerns and focuses on achievable outcomes without wasteful consideration of a large range of unfruitful, alternative diagnoses and solutions. The expert operates from a deep understanding of

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the total situation, which draws on a relevant research, theoretical, moral and ethical knowledge as well as personal learning and experience. Performance at this stage becomes fluid, flexible and proficient and demonstrates a skilled, analytical ability which is particularly evident in situations with which the nurse has had no previous experience.

The Competence Levels

The competencies presented in this document have been divided into core and specialist competencies. The section on core competencies have been presented in narrative form, while the specialist competencies have been outlined in tabular format, in which the specific competencies required at the level of the competent, proficient and expert nurse have been detailed separately.

Whilst we have identified the core and specialist competencies, it is anticipated that over time these will be developed further to reflect new knowledge and advances in practice.

Section 2.1 Getting Started

How to Use the Framework

The framework describes the specialist competencies that aesthetic nurses must achieve to provide nursing care that is lawful, safe, and effective. In addition to the specialist competencies, nurses are accountable for the care that they give and must also maintain the core competencies of any registered nurse. The competency document will be used initially to support training and education in medical aesthetics and is hoped will provide a useful framework to advance the establishment of accredited qualifications.

There are a number of ways this framework can be used to develop nurses’ knowledge and skills.

The framework sets 3 stages of competence for each competency task; competent, proficient and expert. The nurse will need to look at the competency statements and decide where they fit on the career trajectory in terms of development and what they already do. See appendix 1 for a visual representation of how to use this competency framework as a competency based career trajectory.

How to Produce Evidence to Demonstrate Competence

The nurse is responsible for developing their own portfolio of evidence for each competency, in order to demonstrate that they have achieved it at the identified/desired level. Forms of evidence include: case histories, self- -appraisal via a reflective diary, 360- degree feedback, verification of practice and structured observation of practice. When evidence is gathered, it is important to consider the following:

• ensure the nurse understands the requirements of the competency statement

• review any existing work that could be used to demonstrate competence

• identify whether the available evidence is appropriate. For example; a certificate of attendance of a training day is not evidence of competence

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• what else may need to done to develop a portfolio of evidence? Will someone be giving feedback? Are there further developmental needs? Is there a strategy on how these might be addressed?

• using evidence that covers several competencies, for example, a case study which demonstrates a variety of skills and knowledge.

What is Evidence?

There is a variety of material that you can collect to capture evidence of competence. This may include:

• evidence of supervised practice such as signed observation of undertaking a procedure

• projects

• practice developments/changes in practice

• photographs with patient consent for the purpose of use

• audio recordings

• critical incidents

• reflective diaries

• evidence of qualification

• assessments and appraisals

• publications and presentations

• audits

• teaching packages

• poster

• certificates of attendance with reflection on learning

• evidence of group work

• policy and protocol development

• evidence of membership of advisory groups

• research and evidence- -based review

• witness statements with consent for the purpose of use.

The competency framework lends itself to the assessment of nursing practice at local level in partnership with other healthcare professionals.

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Section 3

The Core Competencies

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Section 3 – The Core Competencies

This section provides an overview of the core competencies that are recognised as being universal to all areas of nursing practice, and which consequently underpin the specialist competencies unique to aesthetic medical practice outlined in this document. Within each of the core competencies presented here, an effort has been made to draw attention to relevant legal, ethical and professional responsibilities that are especially relevant to aesthetic nursing practice. Rather than provide a comprehensive and detailed description of core nursing competencies, the intention is to outline their essential features. Readers are advised to consult the sources cited below and recorded in the reference list at the end of this document to ensure their understanding and adherence to professional obligations in relation to these frameworks.

Legal and Ethical Issues

All nurses must practice within certain legal and ethical frameworks. An understanding of these frameworks is essential for nurses to deliver competent professional care to patients. Nurses workingwithin aesthetic medicine must:

• understand and demonstrate professional accountability and responsibility in their practice and work within the NMC code of professional conduct (NMC, 2015)

• incorporate relevant legal and ethical frameworks into their practice when planning care strategies and be able to justify clinical decisions, for example, by:

o being aware of, and adhering to, protocols for dealing with patients who lack capacity in accordance with the Mental Capacity Act (Department for Constitutional Affairs, 2005)

o complying with the Consumer Protection Act (1987) and the requirements to ensure products, services and devices are safe and fit for purpose

o observing the legislation detailed in the Sale of Goods Act (1979) and ensuring products sold are safe, efficacious and of satisfactory quality. Specifically, that claims made in relation to any product are evidenced- -based

o demonstrating a practical knowledge of advertising standards in relation to promoting medical aesthetic practice and use advertising that complies with the regulatory framework established by the MHRA (2012)

• ensure that standards of patient safety and care are not compromised by any financial consideration, and the patient and their safety is put first at all times

• understand the principles of valid consent and routinely obtain written consent from patients before carrying out an aesthetic procedure

• maintain NMC standards for record keeping (NMC, 2009) and ensure there are policies in place that demonstrate how patient records will be handled and stored in accordance with Data Protection Legislation (Data Protection Action, 1998)

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• ensure they have and publicly display the appropriate professional indemnity insurance that is adequate for the procedures that are being provided to the public (RCS, 2013) (NMC, 2015). PLEASE NOTE: As of 1st July 2014, the RCN no longer provide an indemnity scheme for their members whilst working as an employed or self employed aesthetic nurse (RCN, 2014)

• where treating for injury, disorder or disease, be registered with the Care Quality Commission (CQC) (Health and Social Care Act, 2008).

Risk Management

Competence in risk management is underscored by the ethical principle of non-maleficence - to do no harm – as detailed in the NMC code of professional conduct (NMC, 2015). In relation to aesthetic nursing, competence in risk management means:

• ensuring a safe environment for patients, staff and visitors by:

o maintaining all equipment in good working order

o complying with regulations and risk assessments on manual handling

o ensuring fire safety and protocols for evacuation of premises are in place and that staff receive appropriate and regular training in relation to these procedures

o having and adhering to a lone working policy

o providing disabled access as appropriate

o complying with The Management of Health and Safety at Work Regulations 1999 and undertaking risk assessment to identify risks to employees and the public. For further guidance see: www.hse.gov.uk

o Identify relevant life support training required and undertake training as appropriate. For further guidance in this see: www.resus.org.uk

• recognising and managing common medical emergencies and adverse advents, and reporting them to the relevant individual/body as appropriate (e.g. anaphylaxis)

• Identifying appropriate referral pathways in the management of adverse events

• Understanding and complying with guidelines and regulations in relation to:

o infection control (e.g. hand washing, skin preparation)(NICE, 2012)

o needle-stick injury (NHS Employers, 2013)

o disposal of clinical waste and sharps (RCN, 2007)

o healthcare workers infected with a blood- -borne disease (Department of Health, 1998)

o Control of Substances Hazardous to Health (Health and Safety Executive, 2002).

• taking a leadership role in relation to risk assessment by:

o developing policies and protocols to ensure that safety is a priority in the practice of aesthetics, updating as necessary

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Equality and Diversity

Equality, diversity and human rights (Equality Act, 2010) are defining values of society which underpin all nursing practice. Nurses are expected to promote equality of opportunity for all, giving every individual the chance to achieve their full potential, free from prejudice and discrimination. Aesthetic nurses demonstrate competence in relation to equality and diversity by:

• acknowledging and valuing ‘others’ as individuals and respecting and supporting their preferences

• approaching treatment planning and care without prejudice, and in a collaborative manner which conveys respect for the individual and their choices

• demonstrating awareness of relevant cultural, religious and social factors which may influence treatment choice and the outcomes

• recognising and acknowledging the rights and responsibilities of patients and acts in ways that are consistent with the NMC code of conduct (NMC, 2015), current legislation and local policies and procedures, for example, by:

o understanding issues surrounding human rights, and supporting those who lack capacity or need assistance in exercising their rights (Human Rights Act, 1998)(Mental Capacity Act, 2005)

o recognising discrimination (both direct and indirect), harassment, bullying and inequality, and taking steps to challenge such behaviour and report it to the relevant authorities

• acting as an advocate for the promotion of equality and diversity issues by:

o managing protocol development and implementation which ensures that these issues are acknowledged and do not become a barrier to treatment

o providing effective mentorship and reflective opportunities for less experienced members of staff/multidisciplinary team

o liaising with professional bodies/agencies to improve and enhance the development and implementation of equality and diversity policies

o monitoring and evaluating the way in which equality and diversity issues are addressed in the working environment with a view to determining ways to further improve practice and service provision.

Notwithstanding these requirements, it should be noted that aesthetic services are usually contra-indicated by pregnancy, breastfeeding and those trying to conceive for the safety and protection of the patient, child or foetus. Also, it is generally accepted that the patient should be over 18 years of age to access aesthetic medical services in order to provide full consent for elective, non- emergency procedures.

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Communication, Information Sharing/Management

According to the NMC (2011), nurses must have the requisite knowledge and skills to manage information about patients in order to fulfil their professional responsibilities. In addition, nurses must work within legal, professional and common law frameworks when storing and sharing information about patients, while ensuring that patients’ needs and preferences remain at the centre of care. Therefore, good communication, information sharing and management systems are essential in order for nurses to fulfil their professional duties and to facilitate patients’ active involvement in their care and treatment. In relation to the professional working within aesthetic nursing, competence in this area means:

• communicating effectively with patient and carers, ensuring clarity of information and maintaining their right to dignity and respect

• ensures holistic patient care through information sharing and communication with primary care professionals (i.e. GP), where necessary, following written consent to do so from the patient.

• ensuring patient information leaflets are available to patients in order to facilitate the process of obtaining consent prior to treatment

• understanding and adhering to:

o legal requirements concerning the sharing of patient information (e.g. Data Protection Act, 1998)

o professional responsibilities concerning the dissemination of patient information for educational purposes or through professional publications and events such as conference proceedings

• demonstrating best practice in the sharing of information with patients and peers (NMC, 2015)

• taking a leadership role in relation to:

o the development and deployment of information resources to meet patient needs

o the development, implementation and evaluation of guidelines and protocols, which seek to enhance patient involvement and quality strategies in relation to effective communication and information sharing.

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Medicines Management

The NMC Standards for Medicines Management (NMC, 2007) clearly sets out the minimum standardby which nursing practice should be conducted. Competence in medicines management in relationto aesthetic nursing means:

• complying with professional standards (NMC, 2015) in conjunction with professional medicines management standards (NMC, 2007) medicines management

• understanding the legislation related to the prescription, supply and administration of medicines (GMC, 2008; NMC, (2007); Medicines Act, 1968), for instance, by administering prescription only medicines:

o in accordance with a patient specific direction provided by a qualified prescriber, following a face-to -face assessment of the patient by the prescriber (NMC, 2007)

o to the patient for whom a medicine has been dispensed against a patient specific prescription (Medicines Act, 1968)

o under the supervision of, and by sharing accountability with the prescribing clinician (NMC 2007)

• being familiar with the indications, contra- -indications, interactions, precautions, risks and side effects of any medicines administered

• understanding the appropriate storage, reconstitution and dose range of medicines to be administered

• disposing of prescription only medicines in accordance with legislation (NMC, 2007), and manufacturer guidelines

• achieving registration as an Independent and Supplementary Nurse Prescriber, and:

o only prescribe treatment after a minimum of 12 months experience in aesthetic medicine and when competency is achieved (NMC, 2006)

o prescribe according to best practice models (NPC, 2012; NMC, 2006)

o understand the license status of the drug to be prescribed and the additional considerations and responsibilities when prescribing off label or unlicensed drugs (NMC, 2006)

o meet and maintain standards of proficiency required by the NMC (2006)

o attending to risk assessment and the legal and ethical aspects of practice, for example, recording and reporting drug errors in accordance with national and local protocols (MHRA, 2012, NMC, 2007)

• developing knowledge and understanding of the evidence base for prescribing choices and designing and reviewing protocols for local practice

• undertaking teaching and supervision of junior nurses and/or doctors.

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Clinical Governance

Clinical governance is concerned with ensuring patient care is of the highest possible standard and quality. Nurses have a responsibility to provide evidence that appropriate mechanisms are in place to maintain and improve the quality of care they provide. Key themes in clinical governance systems include:

• A patient focus - how services and care are based on patient needs

• An information focus - how information is used

• A quality improvement focus - how standards are achieved and reviewed

• A staff focus - how staff are developed

• A leadership focus - how efforts to improve patient care are improved and developed

• A public health focus - how inequalities can be reduced and health can be improved.

Aesthetic nurses should ensure that they understand the meaning and requirements of clinical governance, and pay particular attention to, among other things:

• being proactive in the assessment of patient satisfaction in their care, treatment and accessibility to, and quality of, aftercare.

• recognising and facilitating continuous quality improvement in the delivery of care using appropriate audit processes which places patient needs at the centre of care

• implementing and evaluating audit/quality assurance activities to develop and enhance practice

• using clinical governance mechanisms to reflect on and improve own and others practice (e.g. monitoring and reporting of poor practice/mistakes/critical incidents)

• promoting one’s own and others development to facilitate the best care possible

• taking a leadership role in relation to implementing, monitoring and improving audit and quality assurance systems.

For further information on clinical governance, please refer to the RCN website at www.rcn.org.uk/development/practice/clinical_governance.

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Personal Learning and Development

In order to ensure the provision of quality care and to facilitate on-going improvements in practice, nurses must make a commitment to their personal learning and development (NMC, 2011). While this is a core competency for all nurses, the specific requirements in relation to aesthetic nursing are provided in more detail as a specialist competency.

Education and implementation of this knowledge is key to patient care and safety, which enables §nurses, in collaboration with their patients, to assess, plan, implement and evaluate treatment. Through education, specialist aesthetic nurses will maintain nursing competence and stay current with new developments in the treatments they provide. The competencies are a working tool for non- surgical aesthetic nurses and allied health care professionals for structuring and synthesizing empirical, ethical and aesthetic knowledge.

Recommendations from the Department of Health Cosmetic Interventions Review panel April 2013 require evidence of education and training. Registered nurses must also be able to provide evidence of competence for the practice they provide to remain on the NMC professional register. Therefore, in order to practice competently and demonstrate competence in aesthetic nursing care, a registered nurse should initially undertake a form of Adult Nurse Education in non-surgical aesthetic procedures, underpinned by evidence based theory, and practical elements. Adult Nurse Education is combined practical and theoretical learning, within University, at degree level. The BACN recognise that the aesthetics speciality must follow similar educational pathways, however, despite the recommendations, there is no statutory training route or Adult Nurse Education available for nurses wishing to undertake aesthetic nursing practice at an entry level, or indeed continuing professional development. A BACN education committee is looking at the education and training framework for aesthetic nurses. Senior members of the BACN board are driving forwards an educational faculty and collaboration between the aesthetic medical professions to further comply with the Department of Health recommendations. In the interim, nurses have to rely upon non -accredited training and it is advised to read section 4 of the Professional Standards for Cosmetic Practice (RCS, 2013) for further guidance in choosing non-accredited training programmes, until formalised and accredited programmes of education are accessible.

It should be noted that attendance at training courses alone is insufficient to become competent or provide evidence of competence in an area of practice. Direct training followed by a period of supervised practice and learning reflection is also necessary. Therefore, in conjunction with the Royal College of Surgeons (2013), The BACN highly recommend that all practitioners undertake a period of formal or informal mentorship following training courses.

Section 4

The Specialist Competencies

A C C R E D I T E D

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Specialist competency 1: Learning and developmentThe NMC Code (2015) dictates that Registered Nurses must provide a high standard of practice

and care at all times. In order to achieve this, a nurse is required to have the appropriate skills

and knowledge required to perform their duties and must develop these with current evidence

based research through lifelong learning and development. This competency acknowledges

the importance of this and the importance to uphold standards of education and continuing

professional development within aesthetic nursing practice. Within this competency, of personal

learning and development, the development of others is included to facilitate and encourage a

wider learning environment in relation to the development of competence in students and others.

In the absence of sufficient regulation, in order to carry out cosmetic treatments, it is desirable

that nurses will have core training and further appropriate training in advanced practice, e.g. Nurse

Independent Prescribing or as an Advanced Nurse Practitioner.

Competent Nurse Proficient Nurse Expert Nurse

Learning and development of self:



Has undertaken a post registration programme of education and training in the medical aesthetics. Can evidence supervised practice by an expert practitioner in the specialty intended to practice.

Can apply knowledge and skills, attained from post registration aesthetic education and training, into the care and practice that they provide to the patient.

Is able to utilise a wide range of evidence-based research to guide practice decisions and ensure that clinical interventions are undertaken safely.

Use patients own preferences as a source of evidence to guide decision-making.

Participates in research data collection.

Is undertaking or has undertaken advanced study at level 11 or beyond that is relevant to the speciality of aesthetic nursing.

Continues to access appropriate learning and development opportunities from other experts, educational institutes and evidence-based research.

Seeks peer support to initiate performance appraisal, and uses constructive feedback to improve own practice and develop a plan for continued development and improvement.

Critically analyses current evidence, from research, to ensure standards of practice, policies and procedures are up to date and of high quality.

Learning and development of others:

Leads on team learning and development through the implementation of processes and structures (i.e. appraisal process.)

Has undertaken an advanced qualification at degree level that is relevant to the specialty of aesthetic nursing (i.e. V300 Nurse prescribing).

Actively seeks ongoing formal education and other continuing professional development activities.

Contributes within professional organizations.Analyses evidence based research to identify gaps in knowledge and skill.

Integrates evidence based research into the development of clinical practice/


Contributes towards the design and implementation of professional development programs, in aesthetic nursing, at local and/or national level.

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Contributes towards small local research projects, facilitating improvements to practice.

Accesses professional organisations such as the BACN (British Association of Cosmetic Nurses).

Identifies the personal need for continuing professional development and ongoing formal education.

Participates in and meets PREP (Post Registration Education and Practice) requirements as stipulated by the NMC (2011), to maintain professional registration.

Demonstrates PREP through a professional portfolio of evidence.

Reflects upon own practice, using analysis and current evidence base, to identify achievements and areas for improvements.

Participates in performance appraisal in order to identify areas for development.

Uses a structured competency based approach to learning and development.

Understands the roles of mentorship and works with a mentor to plan and achieve personal learning and development goals.


Acts as a mentor to non-professional health care staff, (Where applicable), in order to facilitate their learning and development.

Participates in a team learning and development environment.

Begins to develop teaching skills.

Builds links with higher education institutions to facilitate and encourage the growth and availability of aesthetic nursing education.Plans, designs and implements professional development programmes or competency based programmes of education in aesthetic nursing, at local and/or national level.

Acts as a mentor for proficient nurses.

Acts as a source of expertise in knowledge and skill to provide clinical supervision and training to other professionals.

Acts as a source of expertise within professional organisations (e.g. BACN, Association for Nurse Prescribing).

Contributes to the evidence base of clinical practice, by designing, conducting and presenting a programme of research.

Uses a wide range of teaching skills to facilitate the learning of others.

Acts as a mentor for advanced beginner/competent nurses.

Facilitates the learning and development of others through appraisal and personal development plans.

Actively encourages an evidence based practice culture.

Acts as a role model for evidence based practice.

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Specialist Competency 2: Assessment, Consent and Psychological CareThe process of assessment is a key component of clinical decision-making (Peacock, 2004). Nursing

assessments are based on bio-psycho-social models of care, with the emphasis on caring for patients

as individuals and the concept of holistic care.

As the role of the nurse has developed to encompass prescribing and advanced clinical practice,

there has been an increasing emphasis for nurses to develop history taking and consultation skills,

involving information gathering and information sharing. Part of the assessment process is to

establish if a patient has the capacity to provide valid, informed consent; a process which is bound

by legal and ethical frameworks (RCN, 2011). This involves ensuring that the patient has been given

the appropriate information, such as an explanation of all the risks and benefits of a procedure in

a sensitive and understandable way, with enough time to consider the information and to ask any

questions they may have.

Aesthetics involves an elective decision to undergo treatment; therefore understanding the principles

of a systematic health assessment and the legal and ethical implications of the consent process helps

to ensure that patients are given individualised holistic care, and that they are appropriately informed

with regards to the procedures they are considering (Spear, 2010).

It is important to understand the motivation for seeking non-surgical cosmetic procedures. This

is usually one or more of the following: ageing, self-esteem, relationships, a significant event,

or a change in career. The process of patient assessment should specifically involve attention to

psychological history and care, in order to highlight any psychological contraindication and avoid

patient distress. Patient satisfaction and realistic expectations need to be discussed and explored, as

unrealistic expectations for treatment results can relate to a psychological profile or condition that

may require further exploration or specialist psychological risk assessment before treatment can be

considered (Lyne et al, 2010)


The competent nurse uses knowledge and skills to:

In addition to the skills and knowledge of the competent and proficient nurse the expert nurse:

In addition to the skills and knowledge of the competent nurse the proficient nurse:

Demonstrate fundamental consultation and assessment skills, including; identifying their patients concerns and expectations, a general and specific medical, psychological and social history, historical and planned surgical treatments, current prescribed medications, over the counter medications and supplements, allergies, previous adverse outcomes to cosmetic treatment; and surmise from assessment any relative and absolute contraindications to treatments.

Designs, implements and evaluates assessment protocols, including psychological assessment, based on experience and evidence based review.Designs, implements and evaluates consent protocols, based on experience and evidence-based review.

Is familiar with and utilises various models of consultation.Demonstrates advanced skills in assessment and diagnostic ability to identify patient specific concerns, expectations and treatment options.Utilises a range of tools to aid assessment.Recognises a range of psychological conditions that could impact upon the decision to treat.

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Undertake an examination of the patient’s skin and records objective observations to inform the treatment plan.

Demonstrate familiarity with commonly used skin assessment tools (Fitzpatrick, 1988; Glogau, 1996) (See appendix 2).

Communicate realistic expectations to the patient.Recognise limitations in non-surgical aesthetic procedures vs surgical options and refer where appropriate.

Recognise un/reasonable motivations and un/realistic expectations of treatment outcomes.

Discuss the common signs of body dysmorphic disorder (BDD) (Sarwer et al, 2010).

Identify when to refrain from treatment and refer for further specialist assessment (Conrado et al, 2010).

Recognise risk factors and barriers to informed consent (e.g. capacity, peer pressure – see also the Mental Capacity Act (Department for Constitutional Affairs, 2005).

Access appropriate additional information from other clinicians involved with the patient (e.g. GP or specialist), where appropriate and in compliance with confidentiality, consent and the Data Protection Act (1998).

Recognise the essentials of informed consent (NMC, 2015).

Demonstrate familiarity with the legislation that relates to consent.

Has prepared strategies for the management of patients with mental health conditions.Develops local referral pathways for psychological assessment and care.

Has knowledge of all commonly used and evidence-based non-surgical aesthetic treatments, which may be appropriate conjunctive treatment options for the patient.

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Provide verbal and written information to support and evidence the consent process.

Considers social, spiritual, cultural and language issues of the individual to inform treatment planning and consent.

Identify social and work activities which impact upon the decision to treat, choice of treatment options, the timing of treatment, and ability to comply with after care advice; in order to achieve best patient outcomes.

Demonstrate an understanding of the assessment and consent requirements for the treatment being undertaken, and participates and checks the process has been completed to the patients’ satisfaction prior to treatment.

Assess the patients understanding of pain and pain management (appropriate to specific procedure being considered) and discusses anaesthetic (topical/local) options available (Huss,2012).

Ensure documentation is complete, including before and after photographs, in line with NMC (2009).

Discuss treatment specific aftercare advice; minimising undesirable side effects and complications, and optimise results.

Discuss possible further interventions and recommended treatment intervals to maintain outcome.

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Specialist competency 3: Skin Health and RejuvenationThe skin is the largest body organ and has many functions: protection, temperature control, vitamin

D production, sensation and excretion. The skin is useful in diagnosis as it is easily observed and can

reflect events occurring in other parts of the body. As the body ages there are a number of effects on

the skin, and the appearance of the skin has a significant psychosocial impact. These are all important

considerations when making a skin assessment prior to treatment. Functional medicine utilises

a multi-dimensional patient centred approach for assessing patients and examines interactions

between genetic, environmental and lifestyle factors (Vasquez, 2013). In adopting a functional

medicine approach, skin health and rejuvenation aims to arrest or reverse the effects of these age

related changes, by improving lifestyle, nutritional and biochemical factors, in conjunction with the

administration/application of therapeutic treatment regimes.





Understand the anatomy and physiology of the skin, its appendages and functions, by identifying structures and cells within the epidermis, dermis, subcutaneous layers and skin vasculature.

Discuss the concept of skin barrier function.

Describe the cell nutrients required for cellular function (amino acids, essential fatty acids, glucose, minerals, vitamins, antioxidants and trace elements).

Distinguish between the normal and abnormal pathologies of skin appearance and function.

Discusses age related structural changes in the skin with specific regard to loss of elasticity, fine lines, wrinkles, volume loss.

Demonstrate an understanding of the three biological processes of ageing: oxidation, glycation and inflammation (Oresajo et al, 2012; Polefka et al, 2012).

Discusses and critically analyses the process of cellular senescence (degradative enzymes, growth factors & inflammatory cytokines) and the effect on skin health with reference to the evidence base.

Accesses and demonstrates the ability to critically analyse evidence based, peer reviewed research related to skin health.

Demonstrates the ability to discuss and critically analyse current trends with regards to the cellular/wound repair mechanism in relation to the role of growth factors, angiogenesis and oxidative stress and the impact on aesthetic practice.

Critically analyses and discusses the effects of a having no strict definition for ‘Cosmeceuticals’ and evolving regulatory oversight, (Sivamani & Maibach, 2014) and recognises the increased burden on the skin care provider to understand and critically evaluate the evidence.

Demonstrates the ability to explain the cellular/ wound repair mechanism and the process of cell differentiation.

Discusses the role of skin barrier integrity with regards to Trans epidermal water loss (TEWL), stratum corneum hydration, pH, skin surface lipids (Imhof and McFeat, 2014).

Understands the mechanism of delivery of topical ingredients through the skin barrier.

Discusses modalities for increasing penetration of topical agents (emulsions, barrier degradation, liposomes, nanotechnology penetration enhancement and penetration enhancing devices (Draelos, 2014).

Demonstrates an understanding of the topical active ingredients and their excipients, and their interaction with the skin at cellular level.

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Identify the effects of intrinsic and extrinsic factors on the aging process in the skin (Sadick, Karcher, and Palmisano, 2009).

Identify the risks and skin lesions associated with sun exposure and the implications of not protecting the skin (Polefka et al., 2011).

Discuss how medications and medical history may impact upon skin health.

Discuss how diet, hormones, and stress can impact on skin health and the ageing process.

Demonstrate an ability to undertake a skin assessment/analysis (Brennan, 2012).

Identify skin classifications systems and demonstrate the ability to select the appropriate system for individual patients i.e. Fitzpatrick (1988) and Glogau (1996) classifications systems (Carruthers and Carruthers, 2010). (See appendix 2).

Demonstrate an ability to identify and discuss life style and health considerations to inform appropriate treatment planning and health education.

Identify lifestyle changes the patient may take to improve skin health.

Indicate groups who may benefit from nutritional supplements (limited dairy intake, post- menopausal woman, vegetarians) and identifies access to referral pathways appropriate for this.

Demonstrate the ability to define UV radiation and differentiate between UVA and UVB rays.

Demonstrates an in-depth understanding of the difference between ‘Cosmeceutical’ (retinyl esters, retinaldehyde, antioxidants, hydroxy acids, Peptides, Growth factors and stem cells) and ‘drug’ categories (retinoic acid and hydroquinone > 2%) of anti ageing treatments.

Critically analyses and discusses the role of topical retinoid therapy, types, therapeutic effects, adverse reactions and delivery systems (Bowes, 2013b).

Understands the side effects and safety issues concerning current topical, oral and injectable methods used in skin health and rejuvenation and is educated, trained and experienced in range of treatment modalities available.

Discusses the role of topical agents in synergistically enhancing procedural outcomes (Leah and Jacob, 2014) and minimising procedural complications (bruising, post inflammatory hyperpigmentation).

Demonstrates the ability to discuss the role of protein, vitamins (A, C, E and K), carbohydrates, fat and trace elements (zinc, iron & copper) and their role in tissue regeneration (Markham, 2012).

Demonstrates awareness of skin manifestations of nutrient deficiencies for Vitamin A, B, C, K, Iron, essential fatty acids, protein, calories and zinc (Markham, 2012).

Discusses and selects the most appropriate treatment plan/prescription for the individual; Monitors and evaluates treatment outcomes, modifying the treatment plan as appropriate (Newton, 2006).

Leads on developing and maintaining policies and protocols for accessing referral pathways to dermatology, plastics, nutritionists, dietician, psyco- analyst, psychiatry, CBT services.

Leads on development, implementation and evaluation of strategies for skin health promotion.

Leads on developing and formulating skin care training and assessment for competent/ proficient practitioners.

Manages teaching and development of competent and proficient practitioners in the delivery of skin health and rejuvenation.

Participates in research and clinical audit and activities aimed at improving aesthetic services both nationally and internationally.

Leads on development and updating of skin health and rejuvenation protocols, product selection based on critical analysis of current evidence and audit/ evaluation of practice.

Leads on development, implementation and evaluation of strategies for skin health promotion.

Manages teaching and development of competent and proficient practitioners in the delivery of skin health promotion.

Uses expertise to support and mentor practitioners to develop knowledge of skin health promotion and incorporate it in their practice.

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Identify and discuss the principles behind skin protection and maintenance, in particular the role of topical photo-protectants in skin care (Diffey, 2011).

Identifies physical and chemical sunscreens used in sun protection products and demonstrates the ability to discuss sun protection factor rates with reference to the evidence base (Bowes, 2013a).

Demonstrates knowledge of guidelines with regards to sun protection (NICE, 2011; Bowes, 2013a).

Identify topical ingredients commonly used in skin health and rejuvenation.

Demonstrate an understanding of anti-ageing ingredients found in over-the counter topical agents and how they differ to ‘Cosmeceutical’ ingredients used in aesthetics.

Discuss the role of active ingredients in the treatment regimens recommended for skin health and rejuvenation.

Identify and select an appropriate skin product/treatment plan, with reference to an evidence base. (Eaves and Pusic, 2012, Fromage, 2013).

Discusses the rationale for a range of skin care products and their role in improving skin health, appearance, and maintaining integrity of the skin barrier.

Understand the contraindications and risk factors of chosen skin products/ treatment plan, for the safest, optimal patient outcome.

Demonstrates the ability to discuss management of possible adverse skin reactions and safety issues in relation to topical retinoid therapy and the use of topical antioxidants.

Demonstrates knowledge of the regulation of Cosmetic products within the European Union (EU) under the EU Cosmetics regulation 1223/2009 and the Registration, Evaluation, Authorisation of Chemicals (REACH 1907/2006) for cosmetic ingredients.

Identifies skin lesions or conditions that should be referred for specialist diagnosis and treatment pathways, and works within scope of practice (NMC, 2015).

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Identify common skin reactions that may occur in aesthetic medicine, and demonstrates an ability to recognise adverse skin reactions from those that are temporary physiological events.

Recognise limitations of competency (NMC, 2015) and refer appropriately when presented with a skin condition unknown to the practitioner.

Demonstrate knowledge of appropriate referral pathways and when to use them.

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Specialist competency 4: Chemical peelsChemical peels are used to improve the appearance and texture of ageing skin. There are several

groups of chemical peels available: alpha hydroxyl acids, beta hydroxyl acids, trichloracetic

acid, mandelic acid and pyruvic acid. Chemo-exfoliation is a controlled insult at skin level. An

understanding of the anatomy and physiology of the skin, wound healing repair mechanism, skin

classifications, action and outcome of chemo-exfoliation will ensure safe, appropriate and effective

treatment whilst minimising the risk of adverse events and complications.





Undertake a programme of education/training in chemical peel theory and practice. Undertake chemical peel manufacturer specific training.

Demonstrate an application of the anatomy and physiology of the skin to chemical peel theory.

Work as part of the multi-professional team.

Demonstrate a working knowledge of skin classification tools (e.g. Fitzpatrick, 1988).

Discuss the structure and maintenance of healthy skin and identify pathologies that would be responsive to chemical peeling.

Discuss the classifications of chemical peels (e.g. AHA, BHA, TCA etc) and indications/contraindications and cautions for each.

Devise a treatment plan In concordance with the patient, taking into consideration the patient aims, psychological health, physical needs, and financial considerations(NICE, 2012; GMC 2008).

Implement an appropriate course of skin preparation prior to treatment

Undertakes advanced training in depth control peels, which includes supervision by a member of the multi-professional team.

Uses expertise as part of the multi-professional team to prescribe and undertake medium depth control peels, to the mid-reticular dermis.

Act as a resource to other colleagues in relation to identifying and treating anticipated reactions after chemical peels.

Designs, implements and evaluates policies and protocols for the delivery of each peel group classification.

Participate in appropriate clinical trials to evaluate products within ethical boundaries.

Implement an appropriate course of skin preparation prior to treatment in line with prescribing regulations and with consideration of histological effects.

Is able to diagnose, and manage complications, should they arise.

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Demonstrate effective application of exfoliants and light peels.

Discuss appropriate after care; including written and verbal advice to patients.

Identify complications arising from chemical peels and when to refer

Understand how pH effects depth of penetration

Recognize limits of competence with particular reference to depth of peels used

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Specialist competency 5: Percutaneous collagen inductionPercutaneous collagen induction or medical skin needling offers a safe method of improving the

appearance of the skin. Skin laxity, rhytides, scars and photo ageing are generally treated with

ablative procedures that injure or destroy the epidermis and its basement membrane, leading to

fibrosis of the papillary dermis. The ideal treatment would be to preserve the epidermis and promote

normal collagen and elastin formation within the dermis. Collagen induction therapy takes us closer

to this ideal (Aust et al., 2008)

Percutaneous Collagen Induction Therapy will be referred to as PCIT within this competency.





Undertake a specific initial training programme for PCIT.

Apply knowledge of the anatomy and physiology of the skin to PCIT.

Discuss skin classification in relation to rhytides, photo ageing and the ageing skin using frameworks developed by Glogau (1996) and Fitzpatrick (1988).

Describe the biological and biochemical mechanism of wound healing in relation to PCIT (Stevens, 2002).

Identify and treat indications for PCIT; including skin restoration, skin laxity of the face and/or body, scars post-surgery, trauma scars, acne scars, striae.

Identify contra-indications to PCITSelect the correct needle, roller, device and needle depth for the area/skin type to be treated.

Discuss different types of topical anaesthesia (Emla, LMX4, Ametop, Benzocaine, Lidocaine, Prilocaine, Tetracaine (Muir, 2013).

Understand the risks associated with topical anaesthesia as well as potential side effects and further risks in treating large surface areas (Sobanko, 2012).

Contributes and leads on researching PCIT in further areas of clinical practice such as penetration of topical agents using PCIT.(Fabbrocini et al., 2011).

Critically analyses contemporaneous evidence-based research for treatments and trends in PCIT to improve the standard of patient care in clinical practice.

Leads on developing protocols in PCIT and the implementation for advanced techniques (Setterfield, 2010; Aust, 2010).

Is sufficiently skilled at managing patients who are indicated as suitable for PCIT but with noted cautions in their medical history and oversees their pathway of care.

Has expert knowledge and develops protocols for managing adverse events.

Is confident in the management of complications including long lasting haematomas, retinoid reactions, herpes labialis and others.

Demonstrates an in-depth knowledge of anatomy and physiology of the skin and the rationale for using PCIT.

Is familiar with a range of skin classifications and is able to demonstrate the importance of their use to rationalise the suitability and treatment of PCIT, including post treatment care and topical agents.

Understands the biochemistry of cellular communication, cellular growth factors and the wound healing process (Hart, 2002).

Is familiar with the variety of PCIT devices and their relative benefitsIs developing confidence in ability to critically analyse research developments utilising audit to review and design treatment protocols.

Has developed a confident understanding of the rationale behind all contraindications to PCIT.

Has developed skills in treating more complex conditions such as acne scarring, older patients, body treatments.

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Prepare the skin for treatment and demonstrate an understanding of skin preparation (disinfection) and the application of topical anaesthesia.

Identify minor and common post treatment complications such as erythema, scabbing, discomfort and dryness. (Tosti, 2012).

Recognise the importance of comprehensive post treatment care in avoiding complications.

Discuss the value of supporting PCIT with therapeutic skin care regimes for optimal results (Fernandes, 2005)(Aust et al., 2011).

Uses experience to manage expectations and design tailored treatment protocols for more complex procedures such as hypertrophic scarring, striae and body treatments.

Has developed the expertise to educate the patient in the wound repair process to enable an understanding of PCIT.

Utilises Nurse Independent Prescribing qualification to prescribe and demonstrates knowledge of topical anaesthetics: mode of action, pharmacokinetics, effects on cardiovascular and central nervous system, management of toxicity, recognising and demonstrating ability to manage unwanted side effects (Huss, 2012; Muir,2013).

Has developed the skills and competence for prescribing appropriately to avoid complications such as Herpes labialis.

Understands careful attention must be paid to the particular anatomic location, the total surface area covered, and the duration of anaesthetic skin contact (Sobanko, 2012).

Recognises less common side effects of PCIT including Milia and pustules and is able to support the patient and the competent nurse in the management of events using evidence-based knowledge.

Acts as a source of expertise to less experienced peers and identifies when to refer to a specialist in the best interest of the patients and has referral pathways in place.

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Specialist competency 6: Non-permanent (bio-degradable) dermal fillersNon-permanent (bio degradable) dermal fillers are a means of addressing contour defects and

soft-tissue augmentation. Although the treatment is considered relatively safe, the use of injectable

dermal fillers is a minimally invasive treatment, and as with any medical procedure, there is a risk of

unwanted side effects. Complications may result from a variety of risk factors including inappropriate

patient selection, poor practitioner technique, inappropriate product choice, insufficient medical

history and physiological reaction.

Combining the objective factors that influence filler choice and performance alongside clinical

expertise will provide the patient with an optimal result and achieved expectations with minimal risk.

The competent nurse will be working under the supervision of a proficient or expert aesthetic nurse

or doctor at all times. The competent nurse will already have a minimum level of skills and training in

this competency.





Undertake a programme of training in dermal fillers led by an expert and provides evidence of supervised practice in all areas pertinent to dermal filling.

Evidence competence of development in dermal filler knowledge by the recording of referenced reading material, conference attendance, assessment with experts, online tools, peer discussion and educational courses (NMC, 2011).

Demonstrate the application of knowledge in the anatomy and physiology of the facial skin and underlying structures, into practice when using non-permanent, biodegradable dermal fillers, thereby minimising potential risks during and post treatment (Levy and Emer, 2012).

Demonstrate knowledge of the biochemistry of each different dermal filler product and its interaction with the skin (Alleman and Baumann, 2008).

Continues to lead CPD in clinical knowledge and skills in relation to dermal filler application and can demonstrate this evidence of expert knowledge by the recording of referenced reading material, conference attendance, online tools, peer discussion and educational courses (NMC, 2011).

Leads on clinical treatment and research e.g. large volume of dermal fillers for lipoatrophy and the specialist management of adverse events.

Designs, develops and updates dermal filler protocols based on expert experience and critical analysis of current evidence base (Glaichcohen et al., 2006).

Uses advanced knowledge of anatomical differences between ethnicity, race, gender and age to develop and implement protocols on treating a diverse cross section of patients with understanding and care.

Has undertaken recognised programmes of education/training in advanced dermal fillers and provides evidence of supervised practice in this area.

Has developed practice and demonstrates ability, skills and knowledge in injection techniques with both needle and cannula methods.

Can safely demonstrate skills and knowledge in advanced dermal filling techniques such as:• Volumising the face• Face lifting• Nasal remodelling• Tear troughs• Temples• Hands• Body• Advanced injection techniques• Cannula delivery

Is registered as a Nurse Independent Prescriber, enabling the management of complications requiring prescription medication.

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Select the appropriate dermal filler product for the treatment indication with reference to manufacturer guidelines and biocompatibility to the cellular matrix (Tezel, 2008).

Demonstrate assessment and delivery of appropriate treatment for diverse and ethnic differences; taking into account age, ethnicity, culture, facial structure, gender and skin types.

Discuss the differences between male and female facial anatomical structure, and how to treat appropriately.

Discuss the precautions and contraindications pertinent to each type of dermal filler, i.e.: permanent implants, previous unknown implants, or other aesthetic treatments

Develop an individual patient treatment plan with regular review.

Recognise the indications for treatment with different dermal fillers and can safely and competently demonstrate the following dermal filler procedures:• lip enhancement• scar improvement• nasolabial lines• periocular lines /crow’s feet• fine lines and rhytides• peri oral lines• oral commissures• glabella(Vedamurthy and Vedamurthy, 2008).

Demonstrate safe practice, understanding the rationale for utilising a sterile technique when injecting (Vedamurthy et al., 2010).

Has developed the diagnostic skills in recognising complications such as necrosis, granuloma, sterile abscess, infection, allergy, Tyndall effect and other undesirable outcomes associated with dermal fillers.eg asymmetry (Levy and Emer, 2012).

Demonstrates knowledge and skills in order to manage adverse events/complications, specifically relating to poor injection technique, product choice and biological changes.

Utilises the role of mentorship to Share knowledge and skills with advanced beginners and competent nurses (NMC, 2015) in dermal filling, such as:• Anatomy and physiology of the face and neck• Dermal filling techniques• Treatment planning• Management of complications and adverse events(Brennan-Thorns, 2013).

Demonstrates continuing professional development of existing and new techniques through clinical updates, further recognised training, and literature studies (Jones, 2011).

Demonstrates detailed understanding of different types of local anaesthetic injection techniques (local infiltration, field block and nerve block), indications for use, mode of action, pharmacokinetics limitations, precautions, recognising and demonstrating ability to manage potential side effects (Huss, 2012; Muir, 2013).

Utilises audit to manage, record and evaluate outcomes of injectable treatments within a team and implements relevant changes to dermal filler protocols.

Demonstrates the ability to discuss and critically analyse current trends and complex areas eg, the temporal fossa and tear trough indications (Malholtra, 2011).

Analyses clinical research and legal guidelines for prescribing within a team to develop and adapt local prescribing protocols (NICE, 2012).

Has specialist knowledge and leads in diagnostic ability to recognise that complications and risk factors may be multi-factorial.

Has implemented referral pathways to ensure contemporaneous protocols are in place, such as scanning, biopsy, histology and further management.

Leads on developing knowledge and implementing contemporaneous protocols and management pathways in aesthetic emergencies using evidenced based research.

Uses advanced skills and expertise to support and mentor practitioners to develop their knowledge in dermal filling techniques and the prevention, management and treatment of complications associated with dermal fillers (Bailey, 2011).

Leads in the education of dermal fillers in relation to soft tissue augmentation.

Designs and conducts dermal filler related research for peer reviewed publication.

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Demonstrate the injection of the dermal filler to the correct depth suitable for the chosen product (Dayan and Bassichis, 2008).

Continues to develop, with proficient/expert supervision, clinical skills relating to method, depth and positioning of the needle, for the following techniques:• linear threading• serial puncture• cross hatching• fanning• depot• meso injection(Vedamurphy & Vedamurphy, 2008).

Discuss the rationale of detailed post-treatment care, including after treatment verbal and written advice, out of hours contact and follow up appointments.

Recognise when treatment should be referred and delivered by a proficient or expert nurse, such as: volumising the face, face lifting, nasal remodelling, tear troughs, temples, hands, body,advanced injection techniques, and cannula use.

Understand the importance of recording all events clearly; including emails, telephone calls and other correspondence, and is familiar with information systems and tools for practice.

Record clearly all procedures in a practitioner log book and patient notes (NMC, 2015; 2009).

Describe anaesthetic methods for relieving pain during cosmetic injection procedures (cold therapy, topical agents, local anaesthetic).

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Discuss the indications and contraindications of local anaesthesia, and is aware that local anaesthetic for injection is a prescription only medicine. (Huss, 2012; NMC, 2007).

Administer appropriate local anaesthesia in accordance with NMC (2007) Standards for Medicines Management.

Utilise evidence-based research to continue developing clinical practice in dermal filling and shares new knowledge with other colleagues.

Identify undesirable outcomes specifically relating to poor injection technique, product choice and biological changes and refers, appropriately, to a proficient/expert nurse (Levy and Emer, 2012).

Demonstrate knowledge and management of common side effects which may arise from dermal fillers, such as:• Erythema• Swelling• Bruising• Short term localised skin reaction• Discomfort(Lafaille and Benedetto, 2010.)

Demonstrate an understanding of emergency adverse events (e.g. vascular occlusion, necrosis, allergy, anaphylaxis, arterial puncture), and is familiar with treatment protocols and the skills required for managing risk, early diagnosis and management (Lafaille and Benedetto, 2010).

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Recognise when to seek expert professional guidance and pathways for the management of adverse events.

Identify pathways and protocols in place for the management and/or referral for complications and any aesthetic emergency.(Grunebaum et al., 2009)

Demonstrate knowledge of the appropriate reporting pathways for adverse events (i.e. MHRA yellow card scheme) (MHRA, 2012).

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Specialist competency 7: Chemical denervationBotulinum toxin is used in aesthetic medicine for the relaxation of dynamic facial lines. Botulinum

toxin is the exotoxin synthesised by the anaerobic bacteria, clostridium botulinum. Botulinum toxin-A

is one of seven serotypes of this neuro toxin and is the serotype commonly used in aesthetics. There

are several different commercially available preparations of serotype A, manufactured using different

formulations and purification methods. The different formulations therefore are not interchangeable.

Botulinum toxin-A is a prescription only medicine and is currently licensed for aesthetic use for the

temporary improvement in the appearance of dynamic lines in the glabella region in adults under

the age of 65 years as either Botox®, Vistabel®, Bocouture® or Azzulure®. Botox® and Vistabel® are

also licenced for the temporary improvement in the appearance of canthal lines (crows feet lines) in

adults under the age of 65 years. Any other use is off label. Adverse side effects can occur; therefore

a thorough understanding of the facial anatomy and the implications of prescribing and administering

this product is required, alongside an understanding of the implications and accountability of

prescribing a product off label.





Has undertaken a programme of training in the administration of Botulinum toxin Type A, which has been led by an expert practitioner in the specialty, and provides evidence of supervised practice (NMC, 2008).

Demonstrate the application of anatomy of the muscles of facial expression to the administration of Botulinum toxin type A

Recognise the indications for treatment of dynamic rhytides on the upper third of the face(Belhaouari , 2004; De Maio and Rzany, 2007).

Identify the appropriate Summary of Product Characteristics for the chosen drug, to aid recognition of the precautions and contraindications to chemical denervation.

Monitors and develops practice through audit and evaluation of results.

Utilises current research to expertly develop Botulinum Toxin Type A protocols for use and appraisal by multidisciplinary colleagues.

Uses skills gained in Nurse Independent Prescribing qualification in order to safely and appropriately prescribe the minimum effective dose of Botulinum Toxin Type A (NMC, 2006; NPC, 2012).

Understands the in-depth anatomy of the lower face and neck.

Demonstrates knowledge and expertise of the cosmetic indications of chemical denervation to the lower third of the face, neck, décolleté and axillae

Assess facial characteristics and deliver treatment as above, appropriate to the patient’s anatomy, ethnicity and sexual status (Carruthers et al., 2004).

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Devise a treatment plan In concordance with the patient, taking into consideration the patient aims, psychological health, physical needs, and financial considerations (NICE, 2012; GMC 2008).

Identify the appropriate Summary of Product Characteristics for the chosen drug, to ensure familiarity with the appropriate dose range, reconstitution, needle placement, and injection depth (Rzany et al., 2010).

Undertake informed consent, and specifically; time to take effect, duration of result, cost and the need to repeat treatment to maintain results (NMC, 2015).

Demonstrate supervised practice, whilst working towards Nurse Independent Prescribing qualification (NPC, 1999; DoH 2006; DoH, 2012).

Discuss all medicines legislation, particularly those unlicensed for cosmetic use or whose use is “off label”, and including manufacturer’s instructions on storage, administration and disposal of medicines (DoH, 2012; NMC, 2007; MHRA, 2012).

Record all advice and treatment given; provides aftercare advice, both written and verbal, and include out of hours contact details (NMC, 2009; 2015).

Undertake a follow up consultation, and is able to identify undesirable outcomes, such as asymmetry, ptosis, dry eyes, and deliver remedial treatment, reporting and referring where appropriate (NMC, 2006).

Evaluate patient results using recognised classification systems and uses knowledge to provide feedback for safety and efficacy audit (Glogau, 1996; Carruthers, 2010).

Uses expertise, clinical audit and appropriate to Summary of Product Characteristics to aid assessment of several different Botulinum Toxin Type A products and makes justifiable selections for using different formulations, where appropriate.

Uses proficiency and knowledge in Botulinum toxin type A treatment to develop, inform and update patient literature and consent forms.

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Specialist competency 8: SclerotherapySclerotherapy is the introduction of a foreign substance (sclerosing solution) into the lumen of a

vessel. The mechanism of action for sclerosing solutions is to produce endothelial damage which

leads to occlusion of the vessel. Within aesthetics sclerotherapy is used for the treatment of unsightly

telangiectatic/reticular vessels of the lower limbs. There can be adverse complications and sequelae

associated with sclerotherapy therefore it is important for the practitioner to possess (in addition to

a competent injection technique) an in depth knowledge and understanding of the vascular anatomy

and physiology of the vessels of the lower limbs, competency in assessing vessels of the lower limbs,

knowledge of classification system of lower limb vessels.





Practice under the supervision of a proficient nurse or doctor to an agreed protocol.

Recognise patients who have absolute contraindications and exclude them from treatment.

Understand the normal anatomy and physiology of the venous system in the legs.

Understand the aetiology of venous disease (Porter and Moneta, 1995).

Understand the signs and symptoms of venous disease.

Understand the pharmacodynamics and pharmacokinetics of the sclerosant prescribed.

Demonstrate appropriate injection technique to safely treat Weiss type 1,2 and 3 veins (Weiss, Feied and Weiss, 2001).

Understand the role graduated medical compression hosiery plays in minimising risk and promoting best treatment outcomes (Weiss and Weiss, 1990.)

Use expertise to contribute and lead on protocol development.

Undertake analysis of evidence base to design, implement and evaluate policies and protocols.

Has knowledge of the range of treatments available for CEAP 2 veins and educates and refers patients as appropriate.

Has knowledge of recognised CEAP classification of venous disease. (Porter and Moneta, 1995).

Has knowledge of inclusion and exclusion criteria for patients seeking treatment of CEAP Class 1 veins.

Has established referral pathways for patients presenting with CEAP2 veins.

Is able to undertake an assessment of the leg veins using a hand held Doppler to exclude reflux, which contraindicates treatment with microsclerotherapy (Campbell B).

Recognizes when further assessment is required and refers as appropriate.

Has knowledge of the specific medical contraindications and cautions for treatment with microsclerotherapy.

Has knowledge of alternative treatment options and can discuss, advise and refer as appropriate.

Has knowledge of the available sclerosants.

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Understand and can identify contraindications to compression hosiery.

Demonstrate correct measuring, fitting and patient advice to promote compliance.

Understand and communicate aftercare advice.

Demonstrate safe and appropriate treatment planning in partnership with the prescriber and patient.

Undertake a patient follow up and can recognise and manage common complications, but refers to a more experienced practitioner where less common complications occur that require management.

Understands the license status of all sclerosants.

Selects and prescribes the appropriate sclerosant for the individual with reference to legislation, professional standards and the evidence base.

Uses knowledge of aetiology and pathology of venous disease to advise and educate patients (Stott and Davies, 1979; Alexander, 1972).

Has knowledge of side effects and complications.

Is able to administer treatment with techniques to manage risk with reference to the evidence base (Goldman et al., 1995)

Is able to diagnose and manage complications should they arise.

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Specialist competency 9: ThermocoagulationThermo-coagulation is based on the action of heat production through short wave radio and

electrical frequency current to bring about localised destruction of tissues. It works on principle

of tissue fluids being attracted to heat and consequently being vaporised along with the tissue

being targeted. It is commonly used for thread veins on the face and décolletage, whereby heat is

transmitted via a fine gauge needle into the thread veins and causes a coagulation and destruction

of the blood vessel. This method is also adopted for the removal of skin tags, moles, milia and solar

keratosis, however must ONLY be used where no risk of abnormal cells is present, as thermolysed

tissue is unable to undergo histology testing afterwards. As with any procedure that causes a

break in the skins barrier surface, risks such as infection and scarring are present, and should only

be performed by practitioners who have undertaken specific training in the procedure and are

competent in taking infection control measures to reduce these risks.





Undertake a recognised training programme in thermo-coagulation with evidence of supervised practice/mentoring.

Understands the mode of action of thermo-coagulation and maintains the machine in accordance with the manufacturer’s instructions.

Identify the aetiology of thread veins, solar keratosis and skin lesions, including genetic and lifestyle factors.

Discuss health promotion strategies to optimise the results of treatment.

Discuss the rationale behind, and ensure that, patients seeking mole removal have had their moles checked recently by a GP or dermatologist, and is supported with a letter for removal from their practitioner.

Identify basic suspicious characteristics of moles that could indicate carcinoma and is aware of referral pathways to refer appropriately.

Has undertaken advanced assessment and diagnostic skills in dermatology for mole vigilance, and refers to a consultant dermatologist for investigation where suspicious characteristics are present.

Develops dermatology referral pathways.

Leads on developing protocols for safe practice in line with current research.

Utilises Nurse Independent Prescribing qualification to Prescribe for local or topical anaesthesia, demonstrating a detailed understanding of different types of local anaesthetic injection techniques (local infiltration, field block and nerve block), indications for use, mode of action, pharmacokinetics limitations, precautions, recognising and demonstrating ability to manage potential side effects (Huss,2012;Muir,2013).

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Recognise patients who have relative or absolute contraindications and exclude them from treatment.

Identify the appropriateness of treatment in specific anatomical areas with regard to underlying structures and their blood supply.

Discuss the use of topical and local anaesthesia for mole, skin tag, solar keratosis and milia removal and the associated local vasodilation, in relation to bleeding and cautery efficacy.

Understand the risks associated with topical and local anaesthesia as well as potential side effects.

Provide pre and post-treatment information sheets using clear language the patient can understand.

Recognise and manage common complications arising from thermo-coagulation and makes appropriate referrals for management where required.

Uses clinic records to provide an audit trail in effectiveness.

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Specialist competency 10: Laser/IPLLASERs and Intense pulsed light sources (IPL) are based on the principle of selective photothermolysis

(Anderson & Parrish, 1983). By selecting the wavelength that is maximally absorbed by the target

chromophore, and a pulse duration, which is shorter than the thermal relaxation time of the

target, the target can be selectively injured avoiding transferring significant amounts of energy to

surrounding tissues.

LASER and IPL can be used for treating a variety of skin conditions such as vascular lesions,

pigmentation, hair removal, tattoo removal and photo rejuvenation. LASERs are a monochromatic,

coherent light source. IPLs are a broadband non-coherent light source. The decision to use a LASER

over IPL is dependent on manoeuvrability over anatomical structures, the need for real time

visualisation of a target, requiring a level of control where there is a small window between effective

and safe fluences or ultra-short pulses are required such as q-switched LASER for tattoo removal

(Ross, 2006).

IPLs have greater versatility and can be configured for different emission spectra by varying the

current density, filtration or lamp type. The larger hand pieces allow greater skin coverage per pulse.

An in depth knowledge of the skin, LASER physics and LASER safety are required to ensure safe

practice, as there are a number of risks and associated hazards for both patient and operator when

using LASER/IPL.





Demonstrate the application of “Core of Knowledge” Laser/IPL safety training into practice.

Demonstrate the application of system specific manufacturer training and recognises training is not interchangeable between devices.

Demonstrates knowledge of the LASER acronym, different types of laser, electromagnetic spectrum, the basic principles of laser physics and laser tissue interactions.

Differentiate between Laser and IPL and describes the 5 main categories of laser.

Discusses the principles of absorption, reflection and scattering.

Utilises vast experience in different laser /IPL equipment modalities and safety to undertake training and act as a Laser Protection Adviser (LPA).

Leads on service development, laser audit, laser maintenance and record keeping.

Critically analyses evidence base with regards to new and current laser/IPL technology, applications and treatment protocols.

Actively participates in developing and publishing the evidence base for lasers/IPL in aesthetic practice.

Plans, co-ordinates and leads on education for each laser/IPL system.

Has qualification (BTech) in Skin Laser Technology, applications and treatment.

Assists / takes on LPS role controlling laser user access, assisting in audit and development of Laser/IPL protocols.

Communicates with Laser Protection Adviser (LPA) with regard to Local Rules, development of laser protocols and annual audit, emergency procedures, quality control.

Discusses laser/IPL tissue interactions in relation to biological effects (photochemical, thermal, thermo mechanical and photo-ablation) and demonstrates the ability to discuss selective photothermolysis in the context of aesthetic laser/IPL applications.

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Locate and demonstrate an understanding of the local rules for each laser type being used.

Demonstrate the ability to set up laser/IPL system with the appropriate parameters for a specific treatment (wavelength, appropriate hand piece, beam diameter, pulse width, repetition rate).

Prepare a laser room observing the need for a safe environment (e.g. engineering controls and administrative controls) and selects the appropriate laser/IPL safety protection equipment for each laser type.

Demonstrates effective laser/IPL consultation skills, and communicates pre and post care advice.

Demonstrate the application of anatomy and physiology of the skin to Laser/IPL treatments, with specific regard to common vascular and pigment abnormalities, the hair growth cycle, and its relevance in skin rejuvenation and hair removal.

Is able to discuss classification systems in the assessment of common vascular anomalies and pigmented lesions.

Discuss the indications, cautions and contraindications of Laser/IPL, with specific relation to skin type and photosensitivity.

Discuss the rationale for patch testing prior to treatment.

Accurately document treatment parameters used in conjunction with the patient’s name, date of birth and date of treatment.

Demonstrates knowledge of a variety of individual laser/IPL systems used. Is able to discuss beam delivery systems, maximum permissible exposure, pulse width, energy density with specific regard to each individual laser system for a variety of skin applications.

Independently assesses, prioritises, plans, treats, refers on or discharges patients safely following laser/IPL treatment.

Demonstrates the ability to select treatment with the appropriate laser/IPL modality based on patient consultation and assessment and skin typeIs able to access evidence base with regards to each specific laser/IPL system in use.

Demonstrates knowledge of evidence base and available guidelines with regard to LASER and IPL use (Drosner and Adatt, 2005).

Demonstrates ability to manage complications /side effects (redness, bruising, blistering, pain, purpura, hyper/hypopigmentation

Establishes referral pathways for adverse event management, as appropriate.

Assists in the development and training of new laser/IPL users.

Undertakes a programme of training in ablative laser application and use and can evidence a supervisory period with an expert.

Develops referral pathways and protocols for accessing referral pathways to dermatology, vascular, plastics.

Develops policies in relation to the cost of referrals as a result of the complications from treatment.

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Identify that pain is an important marker of possible side effects and is able to identify and discuss potential Laser/IPL side effects/ adverse reactions (Adamic et al, 2007).

Discuss the rationale why anaesthesia should NOT be used in non-ablative laser and IPL treatments, in relation to treatment parameter selection and the importance of patient sensation feedback.

Discuss the use of cooling devices (spray /DCD), zimmer cooling, contact cooling and associated risks with each method.Discuss the use of smoke evacuation systems and when to use them.

Identify established referral pathways and is able to discuss policy/procedures in place for managing adverse reactions (e.g. eye/skin tissue injury).

Demonstrate an awareness of the benefits and hazards of operating a laser/IPL system (eye, skin and associated hazards) and demonstrates knowledge of legislation in relation to these specific hazards: Health and Safety at Work Act (1974), and the regulations related to LASERS under this act (RIDDOR, 1995), Electricity at Work Regulations (1989), Manual Handling Operations Regulations (1992), COSSH (1999), Provision and Use of Work Equipment Regulations (1998), Workplace Regulations (1992), Health and Safety Regulations (1992), Personal Protective Equipment at Work Regulations (1992).

WHERE ABLATVE LASER PROCEDURES ARE UNDERTAKEN, ALSO:

Holds Nurse Independent Prescriber qualification and demonstrates knowledge of topical and local anaesthetics prescribed for ablative laser procedures, such as: mode of action, pharmacokinetics, effects on cardiovascular and central nervous system, management of toxicity, recognising and demonstrating ability to manage unwanted side effects (Huss, 2012; Muir, 2013).

Demonstrates the ability to discuss different types of topical anaesthesia (Emla, LMX4, Ametop, Benzocaine, Lidocaine, Prilocaine, Tetracaine) and local anaesthesia (Muir, 2013).

Demonstrates knowledge of indications, cautions, contra-indications of local and topical anaesthesia.

Prepares the skin for treatment and demonstrate an understanding of skin preparation and the application of topical anaesthesia/administration of local anaesthetic.

Assesses pain and utilises effective methods of pain relief (e.g. oral analgesia, local and topical anaesthetic), adhering to prescription only medication regulations.

Develops referral pathways and protocols for accessing referral pathways to dermatology, vascular, plastics.

Develops policies in relation to the cost of referrals as a result of the complications from treatment.

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Appendices

Appendix 1: Competency Based Career Trajectory

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Appendix 2: Skin classification systems

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Appendix 2: Skin classification systems

Glogau classification

Glogau (1996) developed the traditional rhytide/photoaging classification scheme that is used most often today: Mild (age 28-35 years) - Little wrinkles, no keratosis, requires little or no makeup for coverage Moderate (age 35-50 years) - Early wrinkling, sallow complexion with early actinic keratosis, requires little

makeup Advanced (age 50-60 years) - Persistent wrinkling, discoloration of the skin with telangiectasias and actinic

keratosis, always wears makeup Severe (age 65-70 years) - Severe wrinkling, photoaging, gravitational and dynamic forces affecting skin,

actinic keratosis with or without cancer, wears makeup with poor coverage

Fitzpatrick classification

Fitzpatrick (1975) reported an alternative classification system that is useful in assessing the degree of perioral and periorbital rhytidosis:

Class I - Fine wrinkles Class II - Fine-to-moderately deep wrinkles and moderate number of wrinkle lines Class III - Fine-to-deep wrinkles, numerous wrinkle lines, and redundant folds possibly present

Fitzpatrick also correlated these 3 classes with the following scoring system and degree of elastosis:

Class I (score 1-3) - Mild elastosis Class II (score 4-6) - Moderate elastosis Class III (score 7-9) - Severe elastosis

Mild elastosis is defined as fine textural changes with minimal skin lines. Moderate denotes a yellow discoloration of individual papules (papular elastosis). Severe describes marked confluent elastosis with thickened, multipapular, and yellowed skin. In contrast, the Fitzpatrick classification categorizes according to sun-reactive skin type rather than degree of photodamage. This classification helps identify patients who have a propensity for photodamage. For facial resurfacing, this classification can also be used to define the risk of pigmentary changes (eg, dyschromia, postinflammatory hyperpigmentation, permanent hypopigmentation) with resurfacing procedures. The Fitzpatrick classification of skin types is as follows:

Skin type I - Very white or freckled, always burns Skin type II - White, usually burns Skin type III - White to olive, sometimes burns Skin type IV - Brown, rarely burns Skin type V - Dark brown, very rarely burns Skin type VI - Black, never burns

!

!Suzanne Armstrong RGN, RMN, NIP, Dip PSN, BSc Suzanne began her nursing career in Glasgow in 1981 and worked as a staff nurse or charge nurse in various areas including; emergency medical receiving, bone marrow transplants, plas=c surgery and acute mental health. Laterally she was employed as the business and contracts manager for a Scowsh healthcare trust. Suzanne moved into the field of medical aesthe=cs in 1996 and has worked full =me there since, alongside two surgical colleagues. She was a founder member of the Royal College of Nursing forum for aesthe=c nurses and sat on the steering commiQee for two terms, co-‐ordina=ng the development of the original competencies and co-‐authoring; • The Na=onal Care Standards for Specialist Clinics (Scotland) -‐ 2004• The RCN Aesthe=c Nursing Competencies: an integrated Career and CompetencyFramework – July 2005. • The Assessment Tool for nurses in Aesthe=c Medicine – August 2007.• University of Greenwich Graduate Diploma in Aesthe=c Medicine – 2008• The Good Prac=ce Guide – 2008• The RCN competencies and framework for nurses working with HIV-‐associated faciallipoatrophy in adults. -‐2009 • The BACN Aesthe=c nursing Competency Framework – September 2013Suzanne has worked as a training manager and consultant for a considerable number of pharmaceu=cal and biomedical companies, which has allowed her to learn from colleagues worldwide. She currently represents the BACN on the Cosme=c interven=ons high quality care subgroup at the Department of Health. Suzanne has recently successfully completed NUR208 and NUR228 at S=rling University, and looks forward to con=nuing her studies towards a Master’s degree. !!Adrian Baker RN, NIP Adrian began his nursing career as a heath care assistant working in various secondary healthcare sewngs, before enrolling to become a registered nurse. It was during his nurse educa=on that he found primary care nursing to be of interest to him, and applied to become a community staff nurse with the district nursing teams, as soon as he qualified. Since that =me Adrian has studied, at degree level, a founda=on in community and prac=ce nursing, aQaining a wealth of knowledge and core skills for primary care prac=ce. Aser 3 years of working in the NHS, Adrian made a leap of faith to pursue a career in private aesthe=c nursing at MBNS & Qu=s Advanced Skin Clinics, where he was mentored by Marea Brennan Thorns using the original RCN aesthe=c nursing competencies and competencies tool kit. This guided his introduc=on into aesthe=c nursing, using a structured approach to learning the new skills and knowledge required. Adrian has been working within aesthe=c nursing for 4 years now and successfully completed his independent nurse prescribing qualifica=on to further strengthen his skills within aesthe=c medicine. He has since been awarded the =tle of ‘Aesthe=c Nurse of the Year’ 2014, from the Bri=sh Journal of Nursing. Adrian ini=ally contributed to The BACN Aesthe=c nursing Competency Framework – September 2013, as co-‐author, bringing his personal experience of using the original RCN competencies, as a career pathway, and his academic quali=es of recent study. !!!!!!

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Appendix 3: Biographies

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!Liz Bardolph BSc RGN RM FRSPH NIP A nurse by profession, since 1969 Liz moved on to appointments as Staff Nurse, Ward Sister, Night Superintendent at St Thomas’ hospital and Directorate Nurse Manager in Lewisham. Aser having her family she spent eleven years in clinical research, in parallel with two years of health educa=on in industry. In 1998 she established and managed an independent dermatology laser clinic based in a District General Hospital for eighteen months, before founding Cosmecare in 1999. This is an organisa=on dedicated to providing specialist advice, health educa=on, and treatment of dermatological problems.

Previous aesthe=c experience includes working with RCN, contribu=ng towards local and na=onal policy development and improving standards. She worked on the original competency document and the RCN guide to good prac=ce in aesthe=c nursing. Liz also undertakes consulta=on and treatment in an outreach clinic in Southampton. She contributed towards the development of the first Graduate Diploma Course for Aesthe=c Nurses, and was a visi=ng assessor at the University of Greenwich un=l the last students graduated in 2012. She is an accredited Personal Performance Coach, a Civil Expert Witness, and a qualified Mentor. !Following her consultancy work in li=ga=on, her interests in the legal aspects of aesthe=cs have prompted her to undertake a Masters Degree in Medical Law and Ethics. Liz is currently on the commiQee of the Academy of Bri=sh Cosme=c Prac=ce and the Bri=sh Associa=on of Sclerotherapists. She co-‐founded the Bri=sh Associa=on of Cosme=c Nurses and served on the board as its past President. !Professional aims. She aims to use her experience in aesthe=cs together with her legal knowledge to raise awareness of the legal aspects of aesthe=c medicine, in so doing raising standards in this field of prac=ce. !!Sharon BenneW RGN, NIP Chair, Bri=sh Associa=on of Cosme=c Nurses. !Sharon was an RCN Aesthe=c Forum steering commiQee member, un=l 2009. She is a Founder member of the Bri=sh Associa=on of Cosme=c Nurses (BACN) and is the current BACN Chair. !She ini=ally developed her interest in aesthe=cs 25 years ago, working alongside plas=c and cosme=c surgeons, and has con=nued to develop her skills since then. She has set up and managed cosme=c clinics both in London and overseas and was significantly involved in introducing the first Hyaluronic Acid fillers into the UK in 1996. This generated a par=cular interest in dermal injec=ng techniques, training and educa=on, leading to governance within aesthe=c nursing. !She is the BACN representa=ve on the Bri=sh Standards Ins=tute /CEN commiQee for the Aesthe=c Surgery Services Standard, and is the current Editorial Lead for its Non Surgical Aesthe=c Medical Services Dras standard. She is on editorial advisory boards within aesthe=cs and is working on educa=onal projects within the industry. !Sharon is currently a working director of Harrogate Aesthe=cs, works alongside other suppor=ng specialists to provide a complete service, and runs an aesthe=c clinic within a private hospital group. !Working on the competencies on behalf of all cosme=c nurses has been educa=onal journey. It has been an opportunity to expand my personal knowledge base on the wider requirements in delivering safe and well managed aesthe=c treatments, and is sa=sfying to be integral in the rapidly growing recogni=on of the exper=se UK nurses hold in aesthe=cs, and it’s increasing acceptance as a mainstream specialty. !

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!Emma Davies RGN, NIP Emma qualified as a nurse in 1987 at The Royal Free Hospital, London. She held a number of posts as staff nurse, junior sister then site manager/bed manager before leaving the NHS to work full =me in aesthe=cs. Emma has specialised in aesthe=c medicine since 1998, both in her own clinic and on a sessional and consultancy basis for other clinics. She is experienced in all non-‐ surgical treatments but has a special interest in the remedial treatment of veins. !Emma established, Veincare Training, in partnership with a vascular consultant in 2003, and has since trained over 500 nurses and doctors in this technique gaining the reputa=on of the premier training in micro-‐sclerotherapy, aQrac=ng delegates from all over the world. !In addi=on to her clinical work Emma has par=cipated at a poli=cal level, working with others to promote standards and educa=on in aesthe=cs. She was a commiQee member on the steering group of the Royal College of Nursing Forum for Aesthe=c Nurses Steering CommiQee 2000 -‐2010. Emma founded The Bri=sh Associa=on of Sclerotherapists in 2003 to bring together vascular and aesthe=c nurses and doctors to share exper=se and host educa=onal events. This associa=on is now recognised by The Vascular Society and interna=onal specialist groups. !Emma was a founder Member and Chair of The Bri=sh Associa=on of Cosme=c Nurses, 2010-‐2014, regularly speaks at conferences and contributes to leading Journals on a range of topics related to aesthe=c medicine. In 2012 she was awarded the Cosme=c News Magazine Gold Winner Awards; as ‘Aesthe=c Nurse Prac==oner of The year’ 2012 and ‘Services to Industry Award’ 2012. !Sharon Dobbs RN BSc (Hons), NIP Sharon qualified as an RN in NZ in 1987. She has 25 years’ experience in Plas=c & Reconstruc=ve/aesthe=c surgery working alongside eminent dermatologists and plas=c surgeons. She qualified as a Plas=c & Reconstruc=ve Surgery Nurse in 1990 and has worked both as a staff nurse in NZ and a Sister of a busy Plas=c Surgical Unit in London. She has a BTech in the use of dermatological skin lasers and assisted in sewng up and running the first dedicated skin laser unit in the UK. She has also run a busy dermatological /laser/aesthe=c prac=ce in London prior to comple=ng a First class Honours degree in Tissue Viability. Sharon is a nurse prescriber and is currently comple=ng her Masters in Advanced Nursing Prac=ce. !Sharon is passionate about skin and wound care. She currently provides Tissue Viability services to the Hospital of St John & St Elizabeth in St John’s Wood, London and also works as an independent aesthe=c nurse prac==oner. Sharon is also passionate about promo=ng educa=on, regula=on and training within the aesthe=c industry. She is an ac=ve member of the BACN.

Michelle Irving RGN, NIP Michelle first qualified as a nurse in 1975. Her previous general experience includes surgical nursing at the Royal Hospital, Sheffield and the Radcliffe Infirmary, Oxford. This was followed by work within the community, both as a District Nurse, and as a Prac=ce Nurse. Michelle is the owner and Director of Cheshire Image Clinic, Chester which she opened in 1989. Michelle and her team hold clinics in mul=ple satellite establishments. This clinic exists to provide informed, honest aesthe=c advice and treatment to healthy adults in a caring, professional manner and a welcoming environment. !Michelle was a founder member of the Royal College of Nursing forum for aesthe=c nurses and was voted twice by her peers onto its steering commiQee. As part of this commiQee, she has been instrumental in co-‐authoring the following: !

• Aesthe=c Nursing Competencies: an integrated Career and Competency Framework – July2005. !

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• The Assessment Tool for nurses in Aesthe=c Medicine – August 2007.• University of Greenwich Graduate Diploma in Aesthe=c Medicine – 2008• The Good Prac=ce Guide -‐ 2008!

Michelle is passionate about improving pa=ent safety, and adding value to the Pa=ent Experience, whilst increasing public awareness through educa=on and example. !Lou Sommereux RMN, NIP With a mental health background Lou qualified as a registered nurse in 1981 and as an Independent Nurse Prescriber in 2011. She moved into the non-‐surgical aesthe=cs specialism in 2002, as clinical Director and owner of the Cosmex Clinic in Cambridge. She is respected for her experience and exper=se as a specialist aesthe=c nurse, is a KOL for Galderma and is asked to present at Na=onal Aesthe=c conferences and submits ar=cles for publica=on. She is a co-‐founder of the BACN (Bri=sh Associa=on of Cosme=c Nurses) which has been awarded best associa=on within the cosme=c industry for 3 consecu=ve years. Lou con=nues to serve on the BACN as vice chair, regional group co-‐ordinator and for the last four years has been the regional group lead for East Anglia. She is dedicated to working with others improving best prac=ce, educa=on and pa=ent safety within the non-‐surgical aesthe=c medicine arena. • She has been instrumental in co-‐authoring the RCN Accredited Integrated Career andCompetency Framework Tool for Nurses in Aesthe=c Medicine 2012. • Serves on the advisory board for Aesthe=c Medicine.• Served on the board for the Journal of Aesthe=c Nursing and is currently a peer reviewer.• Serves on the advisory board for Save Face.• Was a member of the RCN Aesthe=cs Forum.!!!

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Notes

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